6/22/2018

Arbovirus Surveillance: Present and Future

Duane J Gubler, ScD, FAAAS, FIDSA, FASTMH

Emeritus Professor

Program in Emerging Infectious Diseases,

Duke-NUS Medical School, Singapore,

Chairman, Global Dengue & Aedes-Transmitted Diseases Consortium

Arboviruses: A Global Public Health Threat, 20-22 June, 2018, Annecy

6/22/2018

BF - Barmah Forest MAY - Mayaro VEE - Venezuelan Equine EncephalitisCE - California Encephalitis MVE - Murray Valley Encephalitis WEE - Western Equine EncephalitisChik - Chikungunya ONN – O’nyong-nyong WN - West NileCCHF - Congo-Crimean Hemorrhagic Fever ORO - Oropouche WSL - WesselsbronDEN - Dengue RVF - Rift Valley Fever YF - Yellow FeverEEE - Eastern Equine Encephalitis RR - Ross RiverJE - Japanese Encephalitis SLE - St. Louis EncephalitisKFD - Kyasanur Forest Disease SIN - SinbisLAC - LaCrosse Encephalitis TBE- Tick-Borne Encephalitis

DENDEN

DEN

DEN

DEN DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

DEN

JE

JE

JE

JEJE

JE

CHIKCHIK

CHIK

CCHF

CCHF

CCHF

CCHF

MVE

RR

BF

SINSIN

TBE

TBE

CE

WN

WNWN

WN

WN

WN

WN

WN

WN

WN

WSL

ONN

RVF

RVF

RVF

KFD

YFYF

YF YF

YFORO

ORO

OROMaYVEE

VEE

VEE

EEELAC SLE

Global Resurgence of Epidemic Arboviral Disease

WN

WNWN

EEESLE

WN

WNWN

DEN

DEN

DEN

DEN

DEN

POW

YF

JE

DENDEN

RVF

WNV

DENDEN

ZIk

FSTS

CHIKCHIK

CHIK

CHIK

ZIK - Zika

Severe Febrile Thrombocytopenia SyndromeBourbon

BOU

ZIK

ZIK

ZIK

ZIK

ZIK

ZIK

ZIK

ZIk

• Dengue, 1990-2018

• Venezuelan equine encephalitis, 1992

• Pneumonic plague, 1994

• Avian influenza, 1997-2010

• Rift Valley Fever, 1998

• Nipah encephalitis, 1998-1999

• West Nile, 1999-2005

• SARS, 2003

• Zika, 2007-2016

• Swine origin H1N1 influenza, 2009-2010

• MERS-CoV, 2012 -2018

• Chikungunya, 2014-2015

• Ebola, 2014

• Yellow fever, 2016-2018

Major Infectious Disease Epidemics, 1990-2018

We Live in a New Era

Principal Clinical Syndromes Caused by Arboviruses

• Systemic Febrile Illness

• Hemorrhagic Fever

• Meningoencephalitis

6/22/2018

Challenges of Arboviral Disease Surveillance

• Differential diagnosis

• Laboratory Diagnosis

• Unpredictable epidemics

• Physicians low index of suspicion

– Inter-epidemic period

• Mild Illness/Self Treatment

• No early warning system

6

Surveillance for Arboviral Diseases

• Disease Surveillance

• Entomologic Surveillance

Entomologic Surveillance

• Species

• Geographic distribution

• Larval habitats

• Adult behavior

• Seasonal distribution

• Insecticide resistance

• Infection rate

Surveillance for Arboviral Diseases

Entomologic Surveillance

• Can use entomologic surveillance data for multiple diseases, depending on geographic area– Dengue

– Yellow fever

– Zika

– Chikungunya

– Epidemic polyarthritis

– Others

Surveillance for Arboviral Diseases

Disease Surveillance for Arboviral Diseases

Passive

Active

Disease Surveillance for Arboviral Diseases

Passive Surveillance

• Physician Reporting

• Case Definitions

• Mandated by Law

• Monitor Secular Trends

• Sensitivity

DEN_Laboratory Surv.ppt 12

Problems with Passive Surveillance Systems

• Does not exist for most arboviruses

• Low Index of Suspicion

– Inter-epidemic period, silent

• Misdiagnosis by physician

• Mild Illness/Self Treatment

• Insensitive

Active Surveillance for Arboviral Diseases

ACTIVELY MONITOR INFECTIOUS DISEASE TRANSMISSION IN CATCHMENT AREA

Time

Location

Etiology

Disease Severity

Inter-epidemic Period

Early Warning Surveillance for Arboviral Diseases

• Passive syndromic surveillance– Dengue fever-like disease

– All hemorrhagic disease

– All neurologic disease

– Case definitions

• Active/proactive surveillance– Laboratory-based sentinel system

– Algorithm on testing priorities/sequence

– National Laboratories for QC

• Regional Reference Laboratories for QC

Components of Laboratory-Based, Active Surveillance for Arboviral Diseases with Emphasis on the Inter-epidemic Periods*

Sentinel Clinic/Physician Clinical samples from representative

cases of viral syndrome, taken 3-15

days of onset of illness

Representative samples taken year

round and processed weekly for

serology, virus isolation, and PCR**

Fever Alert Clinical samples from representative

cases during outbreaks of febrile

illness

Increased febrile illness in community is

investigated immediately

Sentinel Hospital Clinical and tissue samples taken

during hospitalization and/or at death

All hemorrhagic disease, neurologic

disease, and viral syndrome with fatal

outcome are investigated immediately***

TYPE OF SURVEILLANCE SAMPLES** APPROACH

* During an epidemic, after the etiology is known, the case definition should be more specific and surveillance focused on severe disease.

**All samples are processed weekly for serology and virology

***Serology, virus isolation, PCR and immuno-histochemistry on appropriate samples

Adapted from Gubler,1998

Proactive Early Warning Surveillance Algorithm for Arboviral Diseases

Active, Laboratory-Based Syndromic

Surveillance

Test for common pathogens

PositiveNegative

Other pathogens; virology Virology

Need a Comprehensive Early Warning Arboviral Disease Surveillance Program

• Link clinical and epidemiologic disease detection networks to state-of-the-art basic research and diagnostics laboratory

• Regional Program

Country specific

Good lab & epidemiologic capacity

Communications

Leadership18

What is Needed for Arboviral DiseasesSurveillance?

• Investment in sustainable country programs

• Regional reference laboratories

• Standardized Reporting Requirements

– Global

– Regional

– National

• Outreach Programs to Medical Community

• Regional Coordination of Surveillance Data

Infected Patient/Animal

Fieldepidemiology

Clinical & episurveillance

Clinicalcharacterization

Pathogencharacterization

Pathogendiscovery

20

Diagnostic screen

Comprehensive EID Surveillance

Early detection and response

Rural & urbanareas

No disease was ever controlled by surveillance